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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700814
Report Date: 07/01/2022
Date Signed: 07/01/2022 05:55:28 PM


Document Has Been Signed on 07/01/2022 05:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:A LOVING PLACE FOR YOUR PARENTSFACILITY NUMBER:
392700814
ADMINISTRATOR:MARTHA ARREGUINFACILITY TYPE:
740
ADDRESS:488 POELSTRA COURTTELEPHONE:
(714) 948-0381
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY:6CENSUS: 4DATE:
07/01/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Nataley Martinez, Martha Arreguin, Joel GoldmanTIME COMPLETED:
04:00 PM
NARRATIVE
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The purpose of this Microsoft virtual office visit is to discuss the facilities continued non-compliance with Title 22 Regulations and Health and Safety Code. The facility has shown the inability to remedy the Department's concerns. An informal meeting was held on May 6, 2022 to discuss issues and concerns, but the facility continues to struggle to stay in compliance. Present in the meeting were Licensing Program Manager (LPM) Liza King, LPM Stephenie Doub, Licensing Program Analyst (LPA) Maja Jensen, LPA Sarah Hurt and LPA Arrielle Pascua. Facility representatives include Administrator Martha Arreguin, Licensee Nataley Martinez and Counsel Joel Goldman. LPM King explained the purpose of this meeting.
The facility has previously received 12 A type citations and 6 B type citations since 5/11/21.

Currently, the facility has applied for a Change of Location due to a loss of control of property. The facility is also currently under investigation in relation to a serious personal rights matter and is undergoing financial solvency and trust audits.

New Findings
In relation to the application for a Change in Location, LPA Jensen conducted a resident record review for 5 residents and interviewed the responsible parties for 5 residents. Based on the records reviewed and interviews conducted at least 2 of 5 residents did not receive eviction letters and have therefore been subject to an illegal eviction.

Continued...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814
VISIT DATE: 07/01/2022
NARRATIVE
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LPA Jensen also reviewed a current and prior lease agreement for the facility address of 488 Poelstra Court, Ripon, CA and conducted an interview with the property owner. Based on the review of the lease agreements and the interview conducted the lease agreement was altered after being signed by the property owner, then provided to CCL.

LPA Jensen reviewed a prior lease agreement, hospital discharge records, text messages, an admission agreement and conducted interviews. Through this investigation it was revealed persons excluded have maintained involvement with the facility operations.

LPA Jensen reviewed 5 complete resident files for previous residents in relation to a complaint and determined that 5 of 5 files stated no refunds on the admission agreement and 4 of 5 files had the verbiage related to refunds lined through or scribbled out.

Based on the deficiencies cited above, the Licensee has not exercised general supervision over the affairs of the facility and has not established policies concerning its operation in conformance with regulations and the welfare of the residents in care. Additionally, the administrator(s) have demonstrated an inability to conform to the applicable laws, rules, and regulations.

Per California Code of Regulations (CCRs) - Title 22, additional deficiencies are being cited during this visit. An exit interview was conducted with Licensee Nataley Martinez. A copy of this report and appeal rights were sent to the Licensee via email with a request for electronic signatures.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2022 05:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2022
Section Cited

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(A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.

This requirement was not met as evidenced by:
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Based on record reviews and interviews with 5 of 5 resident responsible parties, at least 2 of 5 responsible parties did not receive written eviction notices. This poses a potential risk to the personal rights of residents in care.
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Type B
07/15/2022
Section Cited

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The admission agreement shall not contain the following:
(1) Any provision that is prohibited from being included in the admission agreement.

This requirement was not met as evidenced by:
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Based on LPA Jensen’s review of 5 former resident’s files, 5 of 5 files contained provisions indicating no refunds which is in conflict with HSC 1569.652(c). This poses a potential risk to the personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2022 05:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2022
Section Cited

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement was not met as evidenced by:

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Based on a record review of the lease agreement and written confirmation from the property owner the lease agreement which was provided to CCL was modified after being signed by the property owner or lessor. This poses an immediate risk to health and safety or residents in care.
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Type A
07/05/2022
Section Cited

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The department may prohibit any person ... who has done any of the following:
(1) Violated, or aided or permitted the violation by any other person of, any provisions of this chapter or of any rules or regulations promulgated under this chapter...
This requirement was not met as evidenced by:
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Based on LPA Jensen’s review of a lease agreement for the facility, hospital discharge notes, text messages, and an admission agreement the Licensee and Administrator has allowed excluded parties to be involved in the operations of the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2022 05:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2022
Section Cited

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The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
This requirement was not as evidenced by:
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Based on a preponderance of evidence that includes 12 Type A deficiencies, 6 type B deficiencies and repeat violations issued in a period of time of less than 14 months as well as the multiple deficiencies issued on this day. This poses an immediate risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 07/01/2022 05:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: A LOVING PLACE FOR YOUR PARENTS
FACILITY NUMBER: 392700814

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2022
Section Cited

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(d) The administrator shall have…
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement was not met as evidenced by:
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Based on a preponderance of evidence that includes 12 Type A deficiencies, 6 type B deficiencies and repeat violations issued in a period of time of less than 14 months as well as the multiple deficiencies issued on this day. This poses a potential risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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